Dental Trauma Permanent teeth Flashcards
epidemiology of permanent dentition trauma
- boy: girl ~ 3:1
- 25% all skl children
- 33% adults
- peak 7-10yo
- 70% not treated
what is the most common cause of permanent teeth trauma
fall
what increases risk of trauma to permanent teeth
- overjet
- absence of competent lips
- OJ >9mm doubles the incidence
what condition in MH may influence tx option?
- Rheumatic fever
- congenital heart defects
- immunosuppression
(not contraindications but additional tx may require)
what is the most common injury in permanent dentition?
(and in primary dentition)
crown fracture (enamel-dentine #)
(luxation in primary dentition)
E/O of permanent teeth trauma
- laceration
- haematomas
- haemorrhage/ CSF (yellow fluid from nose and ears)
- subconjunctival haemorrhage
- bony step deformaties
- mouth opening
I/O of permanent teeth trauma
- soft tissue
- alveolar bone
- occlusion
- teeth
- facial/jaw #
- take radiogrpahs if suspicious of foreign objects
what could tooth mobility in trauma suggest
- displacment of tooth (PDL damage)
- root #
- Bone #
what speical test you can do if suspect of fracture
- tactile test with probe (# line)
- transillumination (curing light at palatal aspect)
What sensibility tests can you do on detailed intro-oral exam of trauma?
Thermal - Ethyl chloride (ECL) or warm Gutta-Percha
Electrical - Electric pulp tester (EPT)
- Compare to adjacent non-injured tooth
- Test on adjacent and opposing teeth as they can receive direct or indirect concussive injuries
- Continue sensibility tests at least 2years after
trauma sticker for permanent teeth
- sinus
- colour
- TTP
- mobility
- EPT
- ECL
- P. note
- Radiograph
What does prognosis of the tooth depend on?
- Presence of infection
- Time between injury and treatment
- If PDL is also damaged
- Type of injury
- Stage of root development
General aim of emergency treatment?
- Retain vitality of tooth by protecting exposed dentine by an adhesive ‘dentine bandage’
- Treat exposed pulp tissue
- Reduction and immobilisation of displaced teeth
- Tetanus prophylaxis
- Antibiotics?
General aim of intermediate treatment?
- +/- Pulp treatment
- Restoration (Minimally invasive e.g. acid etch restoration)
General aim of permanent treatment following trauma?
- Apexigenesis
- Apexification
- Root filling +/- root extrusion
- Gingival and alveolar collar modification if required
- Coronal restoration
what is apexigenesis
vital pulp therapy procedure performed to encourage phsysiological development and formation of root
what is apexification
induce a calcific barrier in root with incomplete formation or open apex of tooth with necrotic pulp
How to manage enamel fracture?
either
- bond fragments to tooth or
- simply grind sharp edges with sof lex polishing bur
and
- take 2 PA radiographs to rule out root # or luxation
follow up
- 6-8 weeks/ 6mo/ 1 year
prognosis
- 0% risk of pulp necrosis
How to manage enamel-dentine fracture?
- Account for fragment
Either
- bond fragment to tooth or
- place comp bandage
and
- Take 2 periapical radiographs to rule out root fracture or luxation
- Radiograph any lip or cheek lacerations to rule out embedded fragment
- Sensibility testing and evaluate tooth maturity
- Definitive restoration
Follow up
- 6-8weeks/6months/1year
Prognosis
- 5% risk of pulp necrosis at 10years
what do you do at trauma review appt?
trauma stamp and
radiograph to check:
- root development - width of canal and length
- comparison with contralateral side
- internal/ external inflammatory resorption
- periapical pathology
what is pulpal survival of ED fracture assoc. with intrusion
0% with open or closed apex
How to manage enamel-dentine-pulp fractures?
Evaluate exposure
- Size of pulp exposure
- Time since injury
- Associated PDL injuries
Choose either
- Pulp cap
- Partial pulpotomy (Cvek Pulpotomy)
- Full coronal pulpotomy
Avoid full extirpation unless tooth clearly non-vital
When and how to perform a direct pulp cap?
- If tiny exposure 1mm within 24hour period
- Trauma sticker and radiographic assessment
- Should be non-TTP and positive to sensibility tests
- LA and rubber dam
- Clean area with water then disinfect with sodium hypochlorite
- Apply CaOH (Dycal) or MTA white to pulp exposure
- Restore tooth with quality composite restoration
- Review 6-8weeks/6months/1 year
When and how to perform partial pulpotomy (Cvek Pulpotomy)?
- Larger exposure >1mm or 24hrs+since trauma
- Trauma sticker and radiographic assessment
- LA and dental dam
- Clean area with saline then disinfect with sodium hypochlorite
- Remove 2mm of pulp with hi-speed round diamond bur
- Place saline soaked CW pellet over exposure until haemostasis acheived
- If no bleeding or can’t arrest bleeding proceed to full coronal pulpotomy
- Apply CaOH then GI then restore with quality composite
- Follow up 6-8weeks/6months/1year
When and how to perform full coronal pulpotomy?
- Begin with partial pulpotomy
- Assess for haemostasis after application of saline soaked cotton wool
- If hyperaemic or necrotic proceed to remove all coronal pulp
- Place CaOH in pulp chamber
- Seal with GIC lining and quality coronal restoration
Follow up - 6-8weeks/6months/1year
what are the option for intra-canal medicament for trauma?
- CaOH (dycal)
- MTA white
- bio dentine
- bio ceramic (total fill)
What is the aim of pulpotomy?
- To keep vital pulp tissue within the canal to allow normal root growth (apexogenesis) both in the length of the root and the thickness of the dentine
success rate of partial and full coronal pulpotomy?
Partial - 97%
full coronal - 75%
How to manage root treatment for immature incisors?
- If tooth non-vital then full pulpectomy required
Clinical problem - no apical stop to allow obturation with GP
Options
- CaOH placed in canal aiming to induce hard-tissue barrier to form (apexification) - not ideal, increased root brittleness and risk of root #
- MTA/BioDentine placed at apex of canal to create cemenet barrier (apical plug)
- Regenerative Endodontic technique to encourage hard tissue formation at apex
What is the technique for Pulpectomy in open apex ?
- Rubber dam
- Gain access
- Haemorrhage control (LA/sterile water)
- Diagnostic radiographic for WL
- File 2mm short of estimated WL
- Dry canal, Non-setting Ca(OH)2 , CW in pulp chamber
- Glass ionomer temporary cement in access cavity and evaluate calcium hydroxide fill level with radiograph
Place CaOH no longer than 4-6weeks after identified as non vital as problems with CaOH apexification - risk of root #
- MTA plug and heated GP obturation
Final coronal restoration
- Once obturation complete
- Consider bonded composite short way down canal as well as in access cavity
- Bonded core
- Try to avoid post crown (invasive, root #)
What are the treatment options for crown-root fracture no pulp exposure?
- Fragment removal only and restore
- Fragment removal and gingivectomy (indicated in # with palatal subgingival extension)
- Decoronation (Preserve bone for future implant)
- Surgical extrusion
- Orthodontic extrusion of apical portion (1. Endo 2. Extrusion 3. Post-crown)
- Extraction (last choice)
What are the treatment options for crown-root fracture with pulp exposure?
- Can be temporised with composite for up to 2weeks
- Fragment removal and gingivectomy (indicated in crown-root fractures with palatal subgingival extension)
- Decoronation (Preserve bone for future implant)
- Surgical extrusion
- Orthodontic extrusion of apical portion (1. Endo 2. Extrusion 3. Post-crown)
- Extraction (last choice)
How can the nature of the trauma be described?
- Separation injury (extrusion)
- Crushing injury (intrusion)
Management of permanent tooth concussion
no tx
follow up: clinical and radiograph 1 month, 1 year
Management of permanent tooth subluxation
- no tx required
- splint if excessive mobility/ tender to bite
- follow up: clinical and radiograph 2 weeks (spint removal), 3 mo, 6 mo, 1 year
What are the critical factors related to an avulsion injury?
- Extra-alveolar dry time (EADT)
- Extra-alveolar time (EAT)
- Storage medium
In avulsion, when is PDL viable and non-viable ?
- PDL viable mostly (replanted immediately or v shortly after)
- PDL viable but compromised (kept in saline/milk, total dry time <60 mins)
- PDL non-viable (dry time >60 mins regardless of what happened after this time)
- After dry time of 60 mins or more, ALL PDL cells are NON VIABLE
What is the emergency advice for an avulsed tooth?
- Ensure permanent tooth
- Hold by crown
- Encourage attempt to place tooth immediately into socket
- If the tooth dirty, rinse it gently in milk, saline or in the patient’s saliva and replant
- Bite on gauze/handkerchief to hold in place once replanted
- Seek immediate dental advice
What are the only storage medium you should place an avulsed tooth into?
- Milk (Most preferred)
- HBSS (Hanks balanced salt solution)
- Saliva
- Saline
- Water (poor medium and least preferred)
Avoid dehydration of tooth tissue
How to manage an avulsed tooth with a closed apex that has already been replanted?
- Clean the injured area
- Verify replanted tooth position and apical status
- Clinical & radiographic
- Place passive flexible splint (2 weeks)
- Suture gingival lacerations, if present
- Consider antibiotics and check tetanus status
- Provide post-op instructions
- Follow up 2weeks splint removal/4weeks/3months/6months/1year/annually for 5years
Commence endodontic treatment within 2weeks
CaOH in intracanal up to 1month or corticosteroid antibiotic paste for 6weeks
How to manage an avulsed tooth with EADT<60mins?
- PDL cells may be viable but compromised
- Remove debris
- History & examination with tooth in storage medium
- Replant tooth under LA
- Splint 2 weeks
- Suture gingival lacerations, if present
- Consider antibiotics and check tetanus status
- Provide post-operative instructions
- Follow up 2weeks/4weeks/3months/6months/1year/annually for 5years
Commence endodontic treatment within 2weeks
CaOH in intracanal up to 1month or corticosteroid antibiotic paste for 6weeks
How to manage an avulsed tooth with closed apex with EADT > 60mins?
- PDL cells likely to be non-viable
- Remove debris
- Replant tooth under LA
- Splint
- Suture gingival lacerations, if present
- Consider antibiotics and check tetanus status
- Provide post-operative instructions
- Follow up 2weeks/4weeks/3months/6months/1year/annually for 5years
Commence endodontic treatment within 2weeks
CaOH in intracanal up to 1month or corticosteroid antibiotic paste for 6weeks
How does delayed replantation affect prognosis on permanent tooth with closed apex?
- Poor long term prognosis (ankylosis-related root resorption)
- Decision to replant almost always correct
- Referral to Paediatric Specialist/ Inter-disciplinary management
How to manage an avulsed permanent tooth with an open apex that has already been replanted?
- Clean the injured area
- Verify replanted tooth position and apical status
- Clinical & radiographic
- Place splint
- Suture gingival lacerations, if present
- Consider antibiotics and check tetanus status
- Provide post-operative instructions
- Follow up 2weeks splint removal/1month/2month/3month/6month/1year/annually for 5years
How to manage an avulsed tooth with open apex that has EAT < 60mins?
- Has potential for spontaneous healing
- Remove debris
- History & examination with tooth in storage medium
- Replant tooth under LA
- Splint
- Suture gingival lacerations, if present
- Consider antibiotics and check tetanus status
- Provide post-operative instructions
- Follow up 2weeks splint removal/1month/3month/6month/1year/annually for 5years
How to manage an avulsed tooth with open apex with EAT >60mins?
- PDL cells likely to be non-viable
- Likely outcome is ankylosis-related (replacement) root resorption
- Remove debris
- Replant tooth under LA
- Splint
- Suture gingival lacerations, if present
- Consider antibiotics and check tetanus status
- Provide post-operative instructions
- Follow up 2weeks splint removal/1month/3month/6month/1year/annually for 5years
What is the aim of an avulsed tooth with open apex?
Revascularisation!
- Further development vs risk of external infection-related (inflammatory) root resorption
- Close monitoring
- Endodontic treatment if definite signs of pulp necrosis and infection of root canal system
what is MTA
Mineral trioxide aggregate
When do you not replant an avulsed permanent tooth?
Even as a temporary space maintainer - the right choice is usually to replant
Medical contraindications?
- Child immunocompromised
- Other serious injuries requiring preferential emergency treatment
Dental contraindications?
- Very immature apex and extended EAT (>90mins)?
- Very immature lower incisors in young child finding it difficult to cope?
What is the 5year pulp survival rate of avulsion for open apex and closed apex?
Open - 30%
Closed - 0%
what is the 5 year reosption rate of avulsed/ replanted tooth
frequent
What are the clinical findings of a dento-alveolar fracture of permanent tooth?
- Fracture of alveolar bone which may or may not involve the alveolar socket
- Complete alveolar fracture extending from the buccal to the palatal bone in the maxilla and from the buccal to the lingual bony surface in the mandible
- Segment mobility and displacement with several teeth moving together
- Occlusal disturbance
- Gingival laceration
How to manage a dento-alveolar fracture?
- Reposition any displaced segment
- Stabilise by splinting 4 weeks
- Suture gingival lacerations if present
- Monitor the pulp condition of all teeth involved
Monitor clinically and radiographically for
- Root development
- Resorption
Follow up 4weeks inc splint removal/6-8weeks/4months/6months/1year/annually for 5years
Risk of pulpal necrosis if closed apex is 50% at 5 years
Post-op advice for dento-alevolar fracture?
- Soft diet for 7 days
- Avoid contact sport whilst splint in place
- Careful oral hygiene with use of chlorhexidine gluconate mouthwash 0.12% at separate time of brushing
What are the splinting times for each injury to permanent teeth?
What are the splint properties?
- Flexible and passive
- Ease of placement/ removal
- Facilitate sensibility testing/ clinical monitoring
- Allow oral hygiene
- Aesthetic
fucntion of splint
- maintian reposition in correct position
- favour initial healing and
- providing comfort and controlled fx
What are the types of splint?
Chair side
- Composite & wire gold standard
- Titanium trauma splint gold standar
- Composite
- Orthodontic brackets & wire (must be passive to avoid extra trauma to teeth)
- Acrylic
Lab-made
- Vacuum-formed splint
- Acrylic (useful when few abutment teeth)
What is a composite and wire splint?
- Stainless steel wire up to 0.4mm in diameter
- Quick and easy
- Ensure placed passively
- Flexible (include one tooth either side of traumatised tooth/teeth)
- Don’t place near gingival margin as this can be plaque retentive factor
What is a titanium trauma splint (TTS)?
- Rhomboid mesh structure
- Passive and flexible
- 0.2mm thick
- Easily adaptable with fingers
- Secured with composite resin
when is acrylic splint used?
- only few abutment teeth
- gives full palatal coverage
- acrylic extended to incisal and labial of ant teeth
What are the main post-trauma complications?
- Pulp Necrosis & Infection
- Pulp Canal Obliteration
- Root Resorption
- Breakdown of Marginal Gingiva and Bone
What is pulp canal obliteration (PCO)?
- Response of a vital pulp to traumatic injury
- Progressive hard tissue formation within pulp cavity
- Gradual narrowing of pulp chamber and pulp canal - Result in total or partial obliteration
- Can become opaque or slightly yellow
Treatment: - Conservative management, only 1% may give rise to PAP
What are the types of root resorption?
External
- Surface
- Infection related IRR (inflam root resorption)
- Prev known as external inflammatory resorption
- Cervical
- Ankylosis related RRR (replacement root resorption)
Internal
- Internal infection related IRR (inflam root resorption)
- Prev known as internal inflammatory resorption
What is external surface resorption?
- Superficial resorption lacunae are repaired with new cementum
- Response to localised injury in vital teeth
- Not progressive
- occurs in vital tooth
What is external infection related Inflammatory root resorption (IRR)?
- Occurs in Non-vital tooth with infected pulp canals
Initiated by PDL damage following trauma
- But Propagated by root canal toxins reaching external root surface through patent dentinal tubules
- Rapid
- Can cause cervical resoprtion
Diagnosis: - Indistinct root surface; root canal tramlines intact
- External contour of root, surrounded by bony lucency
How to manage external infection related IRR?
- Remove stimulus by removing infected canal content
Endodontic treatment - Non-setting CaOH for 4-6 weeks
- Obturate with GP
What is ankylosis related RRR?
Initiated by severe damage to PDL and cementum.
- Normal repair does not occur
- Bone cells faster than PDL fibroblasts
Root involved in remodelling
- Radiograph: ‘Ragged’ root outline; no obvious PDL space
Speed of progression is variable and infraocclusion due to alveolar bone development
tx for ankylosis related RRR
Treatment - No effective treatment and plan for loss once discrepancies in gingival margins of affected tooth compared to contralateral tooth is lower than 3mm then plan loss - assessed by multidisciplinary team
consider decoronation
what type of injury would mostly likely lead to ankylosis related RRR
- luxation
- avulsion
What is internal infection related IRR?
- Due to progressive pulp necrosis
- Infected material via non-vital coronal part of canal propagates resorption by underlying tissue and rapid tissue destruction follows
Radiographic
-Symmetrical expansion of root canal walls (‘ballooning’ of canal)
- Tramlines of root canal are indistinct; root surface intact
How to manage internal infection related IRR?
- Remove stimulus of infected canal
- Endodontic treatment prompt after diagnosis
- Non-setting CaOH for 4-6 weeks
- Obturate with GP
- If progressive, plan for loss
What is the 5year pulp survival rate of concussion injury?
Open apex - 100%
Closed apex - 95%
What is the 5year pulp survival rate of subluxation injury?
Open apex - 100%
Closed apex - 85%
What is the 5year resorption rate of concussion and subluxation injury?
Open apex - 1%
Closed apex - 3%
How to manage an extrusion injury?
- Reposition the tooth by gently pushing It back into the tooth socket under local anaesthesia
- Flexible Splint 2 weeks
Follow up 2weeks inc splint removal /4weeks/2months/3months/6months/1year/annually for 5years
What is the 5year pulp survival rate of extrusion injury?
Open apex - 95%
Closed apex - 45%
What is the 5year resorption rate of extrusion injury?
Open apex - 5%
Closed apex - 7%
How to manage permanent tooth lateral luxation injury?
- Reposition under LA
- passive flexible Splint 4 weeks
- Monitor pulp with sensibility test
- Endodontic evaluation (approx. 2/52 post-injury)
Follow up 2weeks/4weeks splint removal/2months/3months/6months/1year/annually 5years
What happen when tooth with lateral luxation injury has incomplete root formation?
- Spontaneous revascularisation may occur
- If the pulp becomes necrotic and signs of inflammatory (infection-related) external resorption commence endodontic treatment
What happens when tooth with lateral luxation injury has complete root formation?
- The pulp will likely become necrotic
- Commence endodontic treatment
- Corticosteroid-antibiotic or CaOH as intra-canal medicament to prevent the development of inflammatory (infection-related) external resorption
What is the 5year pulp survival rate of lateral luxation injury?
Open apex - 95%
Closed apex - 25%
What is the 5year resorption rate of lateral luxation injury?
Open apex - 3%
Closed apex - 38%
How to manage a permanent tooth intrusion injury with immature root formation?
- Spontaneous repositioning independent of the degree of intrusion
- If no re-eruption within 4 weeks: orthodontic repositioning
- Monitor the pulp condition
- Spontaneous pulp revascularisation may occur
- If pulp becomes necrotic and infected or signs of inflammatory (infection-related) external resorption: endodontic treatment, as soon as possible when the position of the tooth allows
Follow up 2weeks/4weeks inc splint removal/2months/3months/6months/1year/annually 5years
How to manage intrusion injury with mature root formation?
<3mm:
- Spontaneous repositioning
- If no re- eruption within 8 weeks: reposition surgically and splint for 4 weeks OR reposition orthodontically before ankylosis develops
3 -7mm:
- Reposition surgically (preferably) or orthodontically
> 7mm:
- Reposition surgically
Pulp almost always becomes necrotic so start Endodontic treatment at 2weeks or as soon as tooth position allows and aim to prevent development of inflammatory (infection-related) external resorption
Follow up 2weeks/4weeks inc splint removal/2months/3months/6months/1year/annually 5years
how to monitor if spontaneous eruption is happening
- measure distance of incisal edge to adj tooth
for mixed dentition - study model
- ## clinical radiograph
What is the 5year pulp survival rate of intrusion injury?
Open apex - 40%
Closed apex - 0%
What is 5year resorption rate of intrusion injury?
Open apex - 67%
Closed apex - 100%
